Content warning: This article discusses mental health.
An Oxford study from 2024 found that around 31 million women and girls globally met the strict diagnostic criteria for premenstrual dysphoric disorder (PMDD), and a higher proportion had provisional diagnosis “where the condition is suspected but symptoms had not been measured for a sustained period of time to meet criteria for confirmed diagnosis”.
PMDD brings severe symptoms including depression, anxiety, migraines, suicidal ideation, and cognitive fog that coincide predictably with the hormonal shifts before menstruation. Despite its recognition in the DSM-V (The Diagnostic and Statistical Manual of Mental Disorders), PMDD is routinely misunderstood, dismissed as “bad PMS,” or misdiagnosed as other psychiatric illnesses. For those who have pre-existing conditions such as “mood, anxiety, psychotic, obsessive-compulsive, personality, and trauma-related disorders”, PMDD can potentially worsen or exacerbate symptoms – and this is known as PME by researchers.
during the premenstrual phase, such as depression So someone with a mood disorder like depression, could face aggravated and more intense symptoms during the premenstrual phase of their cycle.
But when cultural stigma clouds access to awareness and treatment – PMDD turns into a double-edged sword. For Asian women, cultural stigma and silence surrounding menstruation and mental health deepen this invisibility, prolonging suffering and isolation.With alarming global statistics showing that over 30% of people with PMDD attempt suicide, and more than 70% experience suicidal thoughts, the crisis demands urgent attention. So why does PMDD remain a hidden emergency in Asian households and healthcare systems? I spoke to advocates, experts and menstruators who are trying to break the cycle.
Understanding PMDD: More Than “Just PMS”
PMDD differs markedly from PMS and requires clinical attention. Its hallmark is a cyclical pattern of emotional and physical symptoms appearing in the luteal phase of the menstrual cycle and resolving soon after menstruation begins. These symptoms can be so severe that they impair social, occupational, and relational functioning. Several scientists and experts have routinely debunked that PMDD is not a hormonal disorder, like polycystic ovarian syndrome.
“South Asians have lower rates of seeking mental health treatment, often due to stigma, cultural misconceptions, or lack of culturally competent care. Estimates of PMDD prevalence in South Asians vary widely, from 4 to 66%, partly because many do not openly voice their symptoms but instead present with depressive, anxiety, or PTSD-like symptoms. Somatisation—interpreting mental health issues as physical illness—is also common, so many consult primary care doctors rather than mental health specialists,” said Dr. Ashwini Nadkarni, Assistant Professor of Psychiatry at Harvard Medical School.
The International Association of Premenstrual Disorders (IAPMD) has an extensive list of physical, emotional, cognitive and sensory symptoms and a self-screen quiz that can help users understand their PMDD journey. There are no clinical tests – such as hormonal, blood tests, MRI/CT scans, urine analysis – that can help diagnose PMDD.
The weight of multigenerational trauma and stigma
Generational and cultural identity shape the layered and complex conversation around menstrual health and mental health too. These notions in turn, result in shaping how symptoms are expressed and understood.
“In Asian and South Asian communities, menstruation is often seen as shameful or something to be kept private, which isolates sufferers and undermines validation of PMDD as a legitimate health issue. This cultural silence means many endure symptoms alone, delaying diagnosis and support,” said Dr Peggy Loo, from the Manhattan Therapy Collective.
She explains: “Stigma around seeking professional help, particularly for menstruation-related conditions, leads to delayed diagnoses or none at all. People feel confused, blame themselves, or believe their experience is unique. Therapy engagement is also hindered as many are the first in their families to invest in mental health care and may downplay or hide it due to fear of judgment. Although awareness is growing, culturally responsive therapists remain scarce.”
Dr. Loo’s therapeutic approach models nonjudgmental curiosity and normalisation – she prioritises discussing PMS, PMDD and reproductive health openly with patients just as she would do with family health or current stressors: “Silence or waiting for patients to initiate these conversations means missed care opportunities”.
The silence around menstruation and mental health in Asian families often stems from generational trauma and entrenched stigma. Dr. Nadkarni says these stigmas emerge from shame, trauma and social norms.
“For example, menstrual discrimination manifests in lack of access to hygiene products in public, or restrictions on worship during menstruation. Mental health stigma is reinforced by collectivist values that frame seeking help as shameful to family honour. Generational trauma models emotional suppression, making breaking cycles difficult but necessary.”
Anna, a 23-year-old Vietnamese-American grew up in a conservative Christian household with four older sisters in North Carolina. In her household, shame and religious values deeply influenced the attitude towards periods and mental health.
“All PMDD symptoms, the mental, emotional and physical effects were basically thrown under the rug and downplayed because my family were Christian and acted like mental health doesn’t exist,” she said.
Anna was finally diagnosed at the age of 19 by medical professionals, after years of severe PMDD symptoms that included depression, anxiety, fatigue and migraines. The stigma silences families and entire generations.
“My older siblings grew up in Vietnam, with a more hush-hush attitude towards periods and all our problems were seen as things that can be ‘prayed away’. My mum had a hard time with her periods too, but she never sought help.”
Today, Anna lives in Arizona where she is an undergrad student and has a group chat with her siblings where they share their struggles with more honesty and vulnerability. “I take antidepressants and I’m seeing mental health professionals. Only two of my older sisters know that I go to therapy and take meds. Sadly, one of them doesn’t believe in its value.”
Aliyah, who is 22 years old and based out of Brighton, UK went on antidepressants at the age of 18. While they helped her PTSD, they did little to help her PMDD symptoms during the luteal phase.
“I was seeing therapists and taking SNRIs, but only a consultation with a hormone specialist this year gave me the diagnosis of PMDD and suspected endometriosis,” she says. Like others, her journey too has been shaped by cultural stigmas in Asian communities regarding mental and menstrual health.
“The stigma is an interesting one because I am a 3rd generation immigrant –my grandparents moved to the UK from Bangladesh – and they never ever helped my mother when it came to periods,” she recalls. “My mother tried to be more supportive to my mental health but did no research and refused to believe that I had a mood disorder. She had no help growing up, and it was hard for her to support me. She did more research and became more supportive after I had a bad episode and my diagnosis.”
These experiences are unique – and vary by age and cultural factors. For 33-year-old Natasha from Texas, the realisation that her bouts of depression, irritability, anger and anxiety emerged after her postpartum depression.
“I had postpartum depression after my second child in 2015 which turned into major depression in 2018, I was on antidepressants and decided to wean off antidepressants in 2021,” she recalls. By mid-2021, Natasha had weaned off antidepressants, but soon after she began experiencing “random bouts of rage, irritability, dissociation, and depression”. It took her several months to realise the pattern—that the episodes only happened right before her period.
In early 2022, she turned to her doctor for answers but was reluctant to restart medication. “I hated them, they made me feel zombified,” she says.
Her doctor suspected PMDD and noted that it remained “underdiagnosed because it’s underresearched,” with some physicians hesitant to name a condition lacking robust studies. After further review, the doctor suggested trying a calcium and vitamin D regimen. “I’m pretty thankful for her, honestly,” Natasha adds.
She began taking supplements and meticulously tracking her cycle. The changes brought some relief: “With that vitamin, I noticed the rage kind of went away, and the irritability wasn’t as bad. I would still dissociate and feel depressed again, though.”
Natasha, whose mother is of Filipino heritage, faced familiar cultural barriers when opening up about her mental and menstrual health. “The only time she talked about anything related to mental health was when she would tell me she was depressed, but that she didn’t need help because she beat it on her own. She didn’t… and that definitely affected me and our relationship growing up,” she shares. Her mother rarely spoke about her own upbringing, apart from saying, “my grandma never hugged her”. Natasha reflects, “So I think there’s a bit of trauma and resistance to talking about feelings there”.
Because of these family dynamics, Natasha says she doesn’t tell her mother anything about her mental health anymore. Even while living together after the birth of her second child, her depression remained unspoken. “I’ve never told her I was diagnosed with PMDD.” Any time Natasha discusses her health, her mother insists on a second opinion. She has also consistently denied that anything could be “wrong” – whether with Natasha herself or with her.
Natasha recalls that, in sixth grade, she tried to talk about possibly having ADHD because she struggled to concentrate and her grades dropped. Her mother’s response: “You just need to try harder”. Today, Natasha has a formal diagnosis for ADHD and is on medication for it, which in turn has further helped manage her PMDD symptoms.
Neurodivergence, postpartum, PTSD and the experience of PMDD and menstrual health challenges remains a neglected realm by medical experts and researchers.
For menstruators outside the gender binary, research and conversations are exclusionary too. PMDD research so far has centred the experiences of cis women, and not acknowledging the diverse experience of non-binary and transgender menstruators.
“It’s supposed to hurt” – the normalisation of pain
In the menstruation experience – pain is normalised, almost seen to many as a rite of passage and essential to womanhood. A Japanese single-arm study in 2020 tested whether online checklist-based PMS education improved symptoms and work outcomes among 3,090 working women aged 25–44. After eight months, only 4.9% sought medical help, with higher income and moderate-to-severe PMS linked to greater help-seeking. Women with moderate-to-severe PMS who accessed care showed significant improvement in intermenstrual symptoms, but there were no notable changes in premenstrual or menstrual symptoms or work productivity. Despite education, most women did not seek medical attention, often citing normalisation of symptoms or time constraints.
Eri Maeda, an associate professor at Hokkaido University who worked on the study, said menstrual education and awareness is increasing in Japan, but cautions about the normalisation of pain. “Many women still take it for granted to endure the pain or discomfort every month, considering it normal and natural. In my research as well, even those experiencing severe symptoms did not perceive them as serious, nor did they seek appropriate treatment. I believe this lack of recognition negatively impacts women’s productivity in their careers and worsens their overall quality of life,” she said.
Dr. Nadkarni points out that a major issue is the lack of cultural awareness in mental health care for Asian and South Asian patients. Providers need both cultural competence—understanding and respecting different values and behaviours—and cultural humility, which means recognising their own limits and learning from patients’ experiences. She adds that training in these areas, along with community-based clinics and education, is vital for improving care.
“Integrated models of care in which a social worker is embedded in the primary care setting can help to achieve this. Culturally responsive evaluation and treatment can mean, first establishing a rapport, encouraging questions and participation, and then collaborating together with the individual. A trauma-informed care approach, in which the treater establishes psychological safety, builds trust, and empowers the individual, all the while integrating cultural awareness, is also critical,” she added.
These struggles aren’t unheard of by activists and innovators who work tirelessly to bridge the gap. An example is Dr Radha Paudel, a menstrual rights activist from Nepal and a member of the Global South Coalition for Dignified Menstruation. She urges that the conversation around menstrual health and mental health go beyond Asia and extend worldwide, especially in the Global South where stigmas around menstruation still persist.
“In my experience of working with menstruators, most of them were unaware that they had PMDD despite extreme symptoms. Their diagnosis also included endometriosis or PCOS but overlooked clear symptoms of PMDD,” she explains. Medical professionals often overlook and dismiss mental health symptoms. Paudel explains that extreme menstrual pain and discomfort is so normalised, that people with PMDD are often seen as someone who are unable to cope with the pain.
“Doctors often dismiss PMDD symptoms and say ‘Oh, it’s supposed to hurt!’ All of this further stigmatises PMDD, and silences menstruators,” she added.
Paudel, however isn’t giving up on hope – she believes through the lens of dignified menstruation, a more open conversation around menstruation can be kicked off and also sensitise people on PMDD. The Dignified Menstruation theory calls itself a holistic and innovative life-scycle approach to address all forms of menstrual discrimination. It reimagines the world free from all forms of menstrual discrimination, including silence, taboos, stigma, shame, abuse, restrictions, violence, and deprivation from resources and services associated with menstruation throughout the life cycle of menstruators in all diversity.
Paudel firmly believes that access to stigma-free menstruation is a right, not a luxury and this includes PMDD. “Menstrual dignity means openly discussing symptoms, causes, and treatments; fostering awareness among individuals, families, and policymakers; and integrating support into education and health systems,” Paudel insists.
Coping Strategies
“Tracking your cycle and mood gives you data to counter self-doubt and lack of validation. Learn from resources like the IAPMD. Sharing your experience with trusted people or professionals helps break isolation,” says Dr Loo.
Paudel calls for systemic efforts that go beyond including governments and policymakers: “We need to start the work around menstrual awareness from the ground up, by including family members, and community. Menstrual awareness isn’t just a women’s issue and we cannot isolate men from it. Male family and community members need to learn how to support women during menstruation or their PMDD phase, and also help unlearn the stigma that surrounds menstruation.”
PMDD’s invisibility in Asian communities is a complex weave of medical and research gaps, cultural silence, stigma, and trauma. Its devastating effects demand far better recognition and response—through culturally competent healthcare, open dialogue, and policy action. In communities where the topic of menstruation immediately triggers shame and embarrassment, conversations around PMDD must come to centre stage – despite being awkward. After all, this silence cannot be ignored any longer.
If you or anyone you know requires confidential support, call Lifeline on 13 11 14 or Beyond Blue.
Top photo source: Canva